Fever ? inflammatory fever ? nervous fever ? typhus fever ? typhoid fevef

sent severally a particular and definite state of disease, which can rea ^ be distinguished by fixed and essential characteristics ? Alas! no. t vague, on the contrary, are our notions respecting the different fori11? f fever, and so indefinite and defective our descriptions of them, that at reading two separate treatises on the disease, we are often unable to 9J whether the type treated of in each be, or be not, the same. Take, f?r Ju stance, the works of Louis and Armstrong. Do these authors describe

reading two separate treatises on the disease, we are often unable to 9J whether the type treated of in each be, or be not, the same. Take, f?r Ju stance, the works of Louis and Armstrong. Do these authors describe same species of fever? Yes, answers one learned physician; undoubt? no, exclaims another, equally learned. What then are we to gather ( such discrepancy of opinion ? This sad and humiliating truth?that as h we have no accurate knowledge of the specific characters of fever, & ^ less of those more minute points of difference which constitute its nurnbef , varieties. Nay, truth compels us to go farther still, and add, that as we do not possess any undisputed, clear, and definite generic descrip^0?^ fever; so that we may well say in the words of Ramazzini, pronounce , him nearly a century and a half since: "Verum quod dolendum est/ annorum chiliades omnes medentium conatus et machinamenta ad naturam explorandam, nedum oppugnandam, pene in irritum cess^j , Quoties cum veterum, turn recentiorum medicinal procerum praestant1 ^ monumenta, et, quae creduntur cedro magis digna, volumina evolvere ?^ volupe est; idem prorsus mihi evenire sentio ac Terentiano seni, qui cUlflfe< \ filii sui causa plures advocatos accersisset, cosque inter se pugnantes deP hendisset, incertior, inquit, multo sum quam dudum." ^ j The objects which have been aimed at in the work before us, are j stated in the preface :? 0ecifi " To assert the claim of the prevailing epidemic to be ranked among fevers, to separate it from some with which it has long been improper '^ t}je . founded, to show at the same time its analogy with others, and to imp1"0 I pathology of all." iv.

1839!
Dr. lioupe/l on Ti/phus Fever. 9/ a tliSeas reiyiarkirjg' that a knowledge of the seat, character, and progress of adverts fe' '8 essential to precision and success of treatment, Dr. Roupell ?ftyphu0fe Va^Ue an(^ ^definite manner in which authors have treated L?ntj0n S This disease has been prevalent for several years past in the Sea *tS outs'i'rtsJ and Dr. R. has treated numerous cases, both at typhus T9n S ^osPital and at St. Bartholomew's. To prevent this, the true oi,r ail't)ironi being confounded, as it too often is, with other febrile diseases, 8h?uld b'Ur ProPoses " to define accurately the malady to which the term Cal D .e restricted, and at the same time to assign to it a proper nosologi-cal^ l0n" ' This has not been accomplished either by Sauvages or l"ecent ' r'ur ^as ^le rea^ character of the disease been elucidated by more Tweec)ieU 8 *n our own C0Untl7-The definitions of Cullen, Sauvages, > and Copland being quoted, are thus commented on.
^evers. ^e.ab?ve descriptions Typhus is considered to belong to the continued f0t as an '13 upon by the more recent authors in this and other countries Gently10 1 disorder, but as one 'nt0 which others may readily be and converted." 6.
The is cq680-^ ^r' ^"'s observations has led him to a different conclusion, that jt Vlnced that the prevailing fever is owing to a certain specific cause; sF>readino.rSJ^es 1 definite course, passing through its stages with regularity, re> the ^fection, and marked in its progress by a distinctive rash. authors f0' ^ave l'ie characteristics of the genuine exanthemata of ?P'lrWas? ^ass it seems correctly and exclusively to belong. This ?|,th?rj h ft0 ^ie nature ?f the disease was stated in a paper read by our H ^ b ?re.^ie College of Physicians in 1831, and was then thought by l^nbr ,or'^nal-He has since, however, discovered that Professor res'?ns n ?f Vienna, had anticipated his views, and to him therefore he a Without C lm ?f ?ri=inalityforeo-Pronouncing, at present, any opinion on the views expressed in Inters Paragraph, we deem it due to Dr. Copland to remind our 'Picti0lla ' ln ^at part of his article on fever which treats of typhus, sarrie be details fully, and with his usual clearness, precisely ?entleiua^lews and opinions for which Dr. R. is contending. But this latter l^ted Cn'i ^ au extraordinary, and almost unaccountable mistake, has ?^6nuin ^ an^'s Definition of Typhoid Fever, overlooking altogether that 5J>toms Wius. Either Dr. R.'s own notions respecting the nature and J^thaveb l'1G ^sease ab?ut which he is writing, are very loose ; or ho y the auth6en not a ^le surprised at the inapplicable description given > Proof L?i the Dictionary. The occurrence of such an error is a eent arf-i0^ truth of those remarks with which we introduced our rr?rs as w ' an(l' ^ we are not mistaken, we shall find other similar t ^r?fes$0r ^?ceet^ But to resume our analysis:? Us of i "lldenbrand's observations refer especially to the epidemic .ar<k o. but he had studied the disease for twenty years and up-^Ple com^ .c'rcumstances very favorable to enquiry. He states that .0^ogion !*p10us typhus has eight stages or periods?1st, the stage of ?.er'od fr lls period he deems instantaneous; 2d, that of incubation? V? t\vp|v to seven days ; 3d, the stage of invasion?duration from 0< s ' ^th, inflammatory stage?duration seven days ; 5th, H u MeDICO-CHIRURG1CAL RfcVlKW. L 0 nervous stage?this continues five or six days, after which ensues, 6th, critical stage, which lasts only a few hours, and is followed by, 7th, stage of remission?during1 this stage the symptoms gradually abate f?r period of seven days, when the patient enters on, 8th, the convalescent sta&j This runs through several weeks, and has no exact period. The Pat,eJ now recovered, is, to a certain extent, exempt from a recurrence of disease, and occasionally finds that some previously existing ailment departed with the fever. The symptoms attendant upon the several stw are detailed at large; but we do not think it necessary to transcribe ^ . fully. On the fourth day from the commencement of the inflame13^ stage, a purpurous rash appears on the surface of the body, particular!)' those parts which are kept warmest. Together with this, the PecU!'s, exanthema of typhus, petechiae, often appear. The former sometimes ", appears in the fifth, or nervous stage; the latter remain and even increas' or now show themselves for the first time if they have not previously^ peared. In some cases the rash does not exist at all, or is so little de j loped as to escape notice. Occasionally it presents itself under the miliary petechiae, and disappears in a few hours; or having been oul ^ usual time, departs without affording corresponding relief. The disease most infectious in the fifth stage. v There are many circumstances which may complicate typhus, and rous irregularities may arise in its course ; but these are common to tyP i with the other exanthemata.
Having quoted Hildenbrand's description, Dr. R. proceeds to c^'-J " whether or not the epidemics which have appeared from time to 11 < and have recently prevailed, ought to be classed with the disorder A described." That of 1831, of which an account was published by author, " presented all the striking features of this malady." Dr-A ^ strong, in his description of the typhus of 1817, notices an " anofl)8 ?| rash," which he had known to be occasionally mistaken for the erup^ji measles or scarlet fever. Petechiae were very common. Huxham, |So account of the epidemic of 1734-5, mentions not only petechiae but M papulae and pustules. Sir John Pringle, treating of the fever which " ji out during the " black assize" of London, in 1750, mentions certainJr^ which were "frequent but not inseparable attendants of the fever." p are," he continues, " the true petechiae," a statement questioned by V[' J who concludes, (we think without sufficient reason,) that what " terms petechiae, may probably have been the rash usually seen i? 1 cases, or perhaps a mixture of both." 1 The fever which prevailed at Genoa in 1799 and 1S00, presently cording to Rasori, petechiae, or an eruption little differing from PeieC ?? or a miliary eruption, or both; from which confused description infers, that the characteristic symptom of typhus must have been PreSJ.
M. Louis, describing the disease which he terms, " gastro-enteritis, P0^/ adynamic, ataxic, typhoid fever," speaks of a rash, rosy, lenticular, ft with sudamina. The other symptoms of the fever corresponded, say5 ^ with those described by Hildenbrand.

0\4
Were, or were not, the various forms of fever alluded to in the f?r jpjo11 paragraphs identical ? We think not, and we are confirmed in our ?P ^ by the authority of Dr. Copland, who distinguishes the true typhus ,are peculiar to the disease in question. Each of these orders -pVe at a Ke W claim some notice at my hands with the hope of being able to Vphus feVpCr-a^ conclusion from particular propositions. r m common with all others, exhibits in the first place all the phenomena incident to symptomatic or secondary fevers. The constituti?^ febrile symptoms which arise in consequence of local inflammation so cl?s , resemble those of idiopathic fever that they cannot often be distinguished, e*c by the history of the case or by the local affection.
?fi It occasionally puts on those signs which are supposed to denote putrescen j euch for instance as extreme prostration, great tendency to gangrene, f?'0^ the evacuations, cadaverous smell of the whole body, copious discharges of and a rapid tendency to decomposition after death. Scarlet fever as is ^ j linown not unfrequently puts on this appalling character. Putrid symp^may also come on during the progress of the measles or small-pox. Theses'?^ therefore may be called accidental and are common to a variety of speC diseases. m It has in the third place some other symptoms essentially its own ; these rash upon the skin, the power of spreading by infection, and the certain Per of duration." 32.
The above division of the symptoms into three groups has an appea1"8^, of accuracy, and the whole passage quoted might be considered by a ficial reader as both very clear and satisfactory. And yet it would scarcely possible to find in any other writer a passage equally calculate'^ exemplify the illogical vagueness which is unfortunately so comm?0 j medical writings. The symptoms of typhus fever " essentially its own't3iu rash upon the skin, the power of spreading by infection, and the c..$ period of duration." What! are not these symptoms equally character of measles, of small-pox, of scarlet fever? How then, speaking of tyP ^ can they be said to be " essentially its own" ? Dr. Roupell is known t0 * a learned man, and when learned men write thus, what can be expected; the common herd ? aj But let us not proceed too fast. Perhaps the doctor meant, tbat.ef abovementioned symptoms, when existing in conjunction with certain0 symptoms mentioned, are pathognomic of typhus fever. Well then; 'e consider the subject in this light. We have already shown that the SJ j. toms composing the third group are common with typhus, to measles, ^ pox, and scarlet fever. Dr. R. himself states that this is the case ^ pect to the symptoms comprised in the second group ; while those 0 third, are common to all fevers, and thence of necessity to measles, sma'1'^ and scarlet fever. Thus all the symptoms of typhus fever are com*11 ,^\ measles, small-pox, and scarlet fever. How absurd such a conda51 And yet to no other can our author's statements lead.
(c Dr. R. devotes five pages to a consideration of the rash of typhuS,tu' quoting the authorities previously mentioned, and in addition aiso Chomel, who states that there is an eruption in the majority of cases* j, Dr. R.'s views are influenced chiefly by the frequent appearance of th'5 f jt, we think it due to him to transcribe the following statements respectin= ^ " There are many circumstances which throw obstacles in the way of 0 e/ ing accurate information respecting the rash in typhus. Patients delay their application to hospitals for several weeks, so that in one c' $ cases it will have disappeared before the disorder came under notice. In b"1 class it will probably be overlooked, for it is often so slight as to escape a ^ an experienced eye. Then again it will not be perceptible on the chest ?r, y# where it is usually expected to be found. On one occasion where it sought for in vain on the front part of the body, it was perceived abund3 the back, which was accidentally examined, owing to the necessity of c?
L 1839] Dr. lloupell on Typhus Fever. 10 86 on their admission, and showed itself subsequently in the The ^Ver> and^th^611 ma7 fairly t>e considered as one of the characteristics of this ^fiQt is s J16. assertion of Sauvages, that it arises from an over-exciting treatltl ?ther e .n^y contradicted by modern experience. For the rash in this as irQ(luctionrUf ^Ve fevers seems to be exhibited more fully, since the general in-aUvages> a co?ling regimen has been adopted and sedulously enforced. To ofthe ]ate obJection against placing typhus among the exanthemata, on account stantly DpneSS w^ich the rash appears, we may oppose the fact, that it is con-The eru^^6^ on third or fourth day. cases brie-ift is of a red colour, the shades of which are various, in some is full &nt* v'v'd? more generally however dusky, and undertoned : if the Very tUreid y developed the cuticle is slightly elevated, and when the vessels are 011 che t eruPti?n is perceptible to the touch. It is most commonly found Cetlt ease tS Vtrun'i and limbs ; sometimes on the face, and was noticed in a re-!?r^ce of ?, Ve reached and occupied the scalp ; nor is it confined to the outer o^th.
body, but extends itself to the lips and lining membrane of the [July ill two days, was admitted into hospital on the 14th of July, and discharg^j well on the 1st of August. The rash appeared on the day after admission the third day of the fever. .

I
The second case was also mild, being unattended with delirium ; (istr.. typhus ever without delirium ?) and the rash, (" a copious eruption of "U5 red spots") shewed itself on the fourth day. The third case was complicated with pneumonia?rash on the fourth day* In the fourth case, " sore throat" was complained of, and the rash peared on the fifth day. . In the fifth case, "the skin was spotted with a rash" on the sixth ^ The late appearance of the rash in this case, Dr. R. attributes to an em? administered on the first appearance of the symptoms. " In several ?\ j instances," says our author, " where the fever commenced in the hosp1J and the same treatment was adopted, no rash could be discovered." i shall hereafter have occasion to advert to this circumstance.
The subject of the sixth case had been ill six days before admission hospital. " There was no appearance of rash when he was admitted . early part of the afternoon, but in the evening, when seen in bed, he covered with it." .j, j In the seventh case, the disease originated in St. Bartholomew's Hosp1 An emetic was given, and no eruption appeared. ^ In the eighth case, the rash had not entirely vanished a month after first appearance.
Dr. R. remarks that " the cases are generally severe ^ which this retardation occurs, and that it seems to be often occasioned ? some deep-seated mischief. The rash then, he continues, " may appeaf a[ various periods, it may be prolonged some weeks, or it may not appeafu ; all, and 1 have seen it recede after having been out for a few hours 0?' We are at no loss for analogous effects in other exanthematous disor" If M. Rayer's work should be consulted, it will there appear that the er ^ tion in measles will sometimes show itself earlier than usual; for i?sta?0i) on the third day, and even sooner. The same author gives us example the other hand of its retardation to the fifth or sixth." In scarlet fever* eruption, it is well known, is sometimes altogether absent.
.p< Nor can the rash of typhus be confounded with that of any other e thematous disease.
fatfl' " It cannot be mistaken for variola, as it never assumes a pustular ' ^ from roseola it is to be distinguished by the following signs, the patch is 51111 it appears later, and there is no itching. fljed| It cannot be confounded with simple erythema, as that is not accoroP3^ by fever ; but from measles it is not in its mere aspect to be distinguish6"'^ indeed it may fairly be conjectured that that epidemic, which Sydenham* ^ ciibes as being measles of an anomalous and malignant form, was real The measles, he says, of 1674 deviated from rule, did not pieserve their J?p the eruption came out irregularly, was often confined to the neck and sbou ^ the bran-like desquamation did not result, peripneumonia more frequent place, and in some cases the fever would last 14 days and more.
.gr,'1 This disease differs from measles in many respects, its duration is 1?"?^ is wanting in the usual precursory affection of the eyes and sneezing; tfiT is more irregular in form, it does not pass progressively from the head ot if to the extremities, and those who have haid the measles are not free ?r attack of this disorder. Which iCerta'n that the disease was the same in the different epidemics to c?nclude a"udes. On the contrary, we have both reason and authority for Seen 'hF ^lat *n some it was widely different.
cited s0 | ras^ *s not accurately described by any of the authors author m . ^'s impossible to say whether it was the same in all. One Dr. ^\. ringle) does not even mention its existence, and we have only ^hirdlln^erence probably did exist. true py ^ate ?f the invasion of the rash varies more than in the F?Urthl^ernat0US diseases.
body Medico-chirurgical Rkview. [Ju') miliaria; at non ita securum, ut illis solis diagnosis superstrui possit; pf eulce enim non raro febrium gastricarum, vel aliarum socice."* Thus wf Joseph Frank. John Peter's testimony is still more conclusive. 1? | description of continued gastric fever, we have the following-passage1 " Interea turn prius, turn hocce morbi stadio, frequentissima ad cutem themata, petechialia, miliaria turn alba, turn rubra, cum illis interdum nllJC j #c.+ What then ? Is gastric fever essentially an exanthematous disease' Dr. Roupell will scarcely go so far as to assert this. Seventhly, We have our author's own authority for the fact, that ' administration of an emetic in the commencement of typhus prevents o? the appearance of the rash. Could the eruption of small-pox be thus vented ? Most assuredly not.;}: ^ That we have discussed this question at such length, has been the estimation in which we hold Dr. R.'s character as a physician. Bu' ,, this, we should have thought it sufficient to allude in general terms to manifest weakness and inconclusiveness of the arguments with which he" attempted to support his views.
,g! Let us now proceed to the next section of the work, the subject of is, the contagious nature of typhus, or, to use the words of our author-'n 1815US t!iStaniIes-^u"n?' l^e volcanic irruption (eruption?) at Sambawa " Prnnt GS were carried by the wind to Java, a distance of 300 miles, able haz?Ut' '-n Bridgewater Treatise, gives an account of the remark-?<*asionVhich aPPearefl 'n 1782, which was of a pale blue colour, and ?f which a strong-and peculiar odour, during the continuance 'n the '.eP1(^ernic diseases prevailed; the same author noticed an alteration and exnl ' ? ^ie atmosphere before the appearance of cholera in 1832, than the ^ ^ ^ 8UPP?sition that a gaseous body considerably heavier Hialaria &1\' 0ccuP'ed its place, and this body he considers as a variety of Casiona]i 1 ve?"etables only, but minute animals, are said to be thus oc-^ecoixin 1-!UsPencIed. Should this be true, we can understand that by the author'sV''?n -?^ Suc^ bodies, disorders may be generated." But our Qri(* howf6^ *s " not to find a source of disease, but to show how easily Wiug. jn lnfectious matters may be conveyed by this medium. The fol-

?ir Qj^
Clc,ents may serve as practical illustrations of the above assertion.
^lane mentions that, an isolated case of scarlet fever occurred Again ,,a s"ip's crew at sea, long separated from intercourse with the land.
?thers f 6 c^ldren at the Foundling Hospital have no communication with fr?m t-0tn one year's end to another; yet measles, and small-pox appear had bee^ l? ^me amona them." Dr. Heberden relates that a man who ^Unicat* Severa* months in the Penitentiary at Millbank, having no comor by clothing, with any one except the persons be-Jy tha^,,0 establishment, who were all free from small-pox, was attacked ?Urhood nt? which, however, at the time was prevalent in the neighfhe ^'seasesa^Ve ^cts, particularly the first, render it probable that infectious atm0s, an(l do propagate themselves widely, through the medium of jXPtanatio 8re' ^ut must not be overlooked that they admit also of other 0 Prove t|nS' anc^ reSard to typhus fever, we have very strong evidence " 0 lat ran?e contagion is very limited. l)^en Persone^-reason'n^ ^en must be founded on the facts which we observe in a h VI health approach those who are infected, or when disease ap- board, yet they were of an ordinary character, and did not preset peculiarities exhibited by those received from the Refuge. But? " The disorder thus imported soon spread itself over the ship, patients ^ mitted for surgical and other complaints were attacked, the residents on suffered from fever of a similar kind, and the immediate attendants were seve ^ visited. There were seven nurses employed in the medical wards, whose it was to attend on the fever patients, and who returned home when off their families on the south bank of the river. Six of these nurses were with fever of this new type, which a third time made its appearance in,a ^ ^ Having discussed the mode in which typhus is propagated, our proceeds to consider the "causes of its production." . 3 tM ; The notion is generally entertained that under certain conditi" poison of typhus can always be generated. Thomson, Hildenbrand; ^ $ Pringle, &c. state it as their opinion, that air overcharged with / halations is the cause of typhus, hospital, or jail fever. But the faCgfltis' duced in proof of these statements do not appear to our author qulte factory.
tjgJJ VJ " There was no such disorder amongst the prisoners at Oxford * if black assize was held there in 1577, on which occasion judges, SeD s io,^ almost all who were present perished to the number of 300 ; the P?TS? 0\)^ I jail alone we are told were not injured by it. Passing over the ira^rs jab0?} of prisoners giving rise to a disease under which they did not themscKeto ( it appears that a malignant fever was at the time prevalent in Oxford' ^ |0^ we are told that '200 more persons of note fell victims besides number^ iflj degree/ Again we are informed that in 1750, when the two judges* Mayor, one of the aldermen, one sheriff, two or three of the counsc l,a$o the jury, and above 40 more died, no uncommon sickness was obser came to the bar or were in Newgate. Now it seems clear London g?evere fever, if not this very disorder, was then prevalent in Th t Ostein Vltlated air, bad food, and all debilitatingcauses will predispose the the ext ? r.eceive infection?that the influence of such causes will lead to but at ,nsion ?f any disease propagated by infection, our author admits; ducjn e ?ame time he denies that such causes are alone capable of profilth ajj?n ,nfectious malady. Several striking instances, in which extreme su ? en.ess failed to originate typhus, are noticed, after which he up his arguments.
?!Sease ^at We can strictl>r 'n^er 's> that debility will predispose to the Stating.
Ut as ^ exists in those previously in robust health, and as when derive, s? causes are present it is not always occasioned, we must look for some ? ?ften t Ia'i and sPecific virus. The germ of this disorder will not, I believe, lt> activit ran^lnS' f?r m some of its various forms it seems to be almost always ^ fln some portion or other of the world, and amongst all civilized com-S'^er how ??e disorders we have any accurate account. And when we conanj r^ad'ly the poison may be conveyed either by the atmosphere, or *'hle of'. .the minute particles which may excite the disorder in those suscepf V'rUs in? ln^Uence> we may more properly consider the disease as extended by esh outbreak" ?Perat*on' t^ian suPPose it to he recently generated on every tradictory facts, but to express also contradictory inferences. He begin3 ' f stating that "another argument in support of the specific nature of tyPD may be derived from the length {definite length, we suppose) of time o& pied by the disease in its progress;" and then quotes certain authors to sn that the usual period of termination is about the twenty-first day. But ^ Louis, whose authority he cites, states that the disease occupied a sPacegI1 from eight to forty days. Hildenbrand assigns to it a duration of four*6 days; and our author himself relates three cases, in two of which the sy^cj toms were at an end within one week, while in the third, convalescence not begin to take place until the nineteenth day.
" These cases," adds J | R. " are quoted with a view of showing the termination of typhus at ent periods;" and yet, as we have already noticed, he sets out by defiy' an argument in support of the specific nature of typhus from its certain P ( riod of duration. We cannot comprehend our author's object in tbu3. once arguing/or and against the same proposition. It is by no means "1 cult to understand what inference he wishes to draw, but the adverse ?a it would appear, were too prominent to be left altogether unnoticed. ^ Dr. R. expresses his belief that the milder cases, above alluded t?^8 having terminated within a week, exhibited the features essential to typhus; and in attempting to show the contradictory nature of his st . ments, we have, of course, been obliged to adhere to his own views. ^ | we are by no means convinced, from his very brief statement of syr?Pt0 ^ that his opinion as to the nature of the disease is correct. To PreV^p however, all possibility of misrepresentation, let us give in our author's 0 ! wurds the details of two cases, calculated, we think, to prove the reas? flf bleness of our doubts.
Indeed, Dr. R. himself, speaking of the cases to which those about to be cited belong, says, " that they cou'" j be positively pronounced to be the disorder now under consideration,"311' fy. he subsequently draws inferences from them, as if the disease was und? edly typhus.
-{?' Case XV.?" George Main, aged 25, had been into one of the Asylu^^'s the Destitute, where fever was prevalent, and was admitted into the Sea"3 jje Hospital on the 2nd of April, 1831. He had frequent rigors, with pain 10' j,jt head, back, and limbs, his sleep at night was disturbed, his skin was soiBe $ warmer than natural, but his pulse was quiet, and there was morbid appcafi $ on the tongue. He had been ill two days. The fever quickly subsided, aD the 6th he was pronounced convalescent.
Ji < Case XVI.?" John Clarke, on admission into the Seaman's Hospital, ^ 4th, 1831, stated that he had been for some time in the Asylum for the Dest' jf# He complained of frequent chills, with pain in the limbs, and coughtongue was clean, pulse 70, weak, skin cool, bowels loose. The head-act?;^ tinued for a few days with confusion of intellect and slowness in aDS jjj^ : questions; after which all completely subsided in a short time. He was dec convalescent on the 8th of March." . .
[($ " These," says Dr. R., " are some of a vast number of instances wl?c^' the general outline of the symptoms, and from the circumstances under The distuh^' Justify the inference that they arose from some specific cause.
a.Qd the co head, the character of the pulse, the state of the tongue, 8i?n ofsi" ltl0n t^ie skin, were not such as would be produced by the acces-sPecifio ri-Ple fe-ver; but such a3 might arise from the modified virus of some w ISOrder, such as typhus." 77.
^ave rfannot' however willing-, assent to the truth of these remarks. We c'rcumst ^atedly known symptoms, similar to those described, exist under fact, Sima?ces whieh the idea of infection could not be entertained. In itig train f ^astr'c derangement will give rise to a completely correspond-re4uires t?h sy.mPtonis, in ill-fed impoverished patients. Scientific accuracy kuild u' *n c^assing' diseases, we have some more certain foundation to lhe rathe"1 ^an a suPPosed community of origin. We insist on this point ePidetnicer ^at medical men are too prone, during-the prevalence of any siCUrrence Convers'?n into the rash is spoken of by some authors as a common J ?Ul{j c ' we might a priori consider it as likely to be the case, for we r0Ql itiiere ajDly exPect that effusions of blood would more readily take place Th ^an ^rom ot^er parts." 81. *6tlCe? a T no doubt that the error lies in the first part of the sen-^etechi(? ' ^at our author meant to speak of the rash as terminating in f^optv^ ^?rm haemorrhage frequently met with, is epistaxis. This, like rptn ls? occurs for the most part early in the disease, while haemorrhage Jjth in t ?Wels comes on at a later period. Bronchitis is constantly met e fever fS' anc^ mor^id secretion often contains streaks of blood. In Verv ? Dr. R. remarked that the haemorrhage from leech-bites the bl ^r^use* Haemorrhage has been ascribed to an altered condition ?o, and this is no doubt one of its causes.

Its frequency in the j 10
Medico-chirurgical Hhvikw, morbus caruleus proves, indeed, how much an altered condition of the bio may favor its occurrence; but, at the same time, Dr. R. believes that ^ state of the vessels themselves in typhus, and the other eruptive fevers, serves more attention than it has hitherto received.
He further adds,' j in typhus, " haimorrhage takes place at one of two distinct periods, the on or about the third day from the attack, the second upon the fourteej^ day, or later." Some cases are given illustrative of the occurrence in typ .
of various forms of hasmorrhage. We transcribe the following1, in w the morbid appearances were highly interesting-.
Case.?"John Michael, aged 16, was brought to the Seamen's Hosprta'o|), the 14th of January, 1832, in a state bordering upon insensibility; he was ^ stantly throwing about his limbs, his face was pale, the pupil of the eye ^ dilated, his breathing was oppressed, he had cough with expectoration of M flf, | and shrank as if he felt pain when pressure was made on the abdomen; the * t face of the body was covered, with petechia;. All that could be ascertained a 5 j him was that he had had fever, with great pain in the head, and that he ha<i delirious for a week.
He died very soon after his admission into the hospital. It was observed ,{ the body retained its warmth 24 hours after death. It was covered with P spots, which were almost entirely confined to the anterior portion of the b? ^ The liver was greatly enlarged and pale. The spleen was soft and larger ^ natural. The lungs were healthy in structure, and with the liver and SP were dotted with petechise.
. ^ Blood had been effused into the left side of the brain at the lower atl part; the upper portion of the spinal chord was surrounded with blood; was effusion of blood also into the substance of the left pectoral muscle. ^ The inguinal glands were enlarged and red, and when cut into yielded15 mixed with a purulent fluid." 87.

'rJlOllS
Erysipelas.?" During the prevalence of the epidemic in various years,l0'j,et thic erysipelas has been a very common and a very serious addition fe to complaints in persons exposed from their situation in hospitals and elsewh^c the vicinity and infection of typhus, and so common was it in the progress? fever during the present year, as well as during that of 1831, that n? t0 th'5 could be entertained that it was essentially connected with and incident disorder. Dr. Bateman noticed it in the House of Recovery, and consider? accessory disease. M. Louis observes, that shivering rarely took place J m. course of the disease except to usher in some new calamity, such as eryslr It seems to arise at two periods, of which one is within the first week, usUg tf as it were the place of the ordinary rash. It prevails at the same ti?e ? giH phus, is preceded by the same symptoms, and arises amongst nurses or tl1 attendance upon the patients ill with that fever." 88. for.
Erysipelas frequently seems beneficial in the later stages of typ"u on its invasion, a train of anomalous symptoms will often at once disflPy< Cases of this kind are given, and also others in which erysipelas alo?e mS, sented itself, in persons who had attended patients labouring under tyP some of whom had erysipelas, and some had not.

($'
The inflammation in typhus frequently terminates in suppuration* ^ lections of pus form in various parts, especially about the face, t,eC' th's head, and still more frequently in the ear. Several cases illustrative complication are given, but we have not space to transcribe them.

gjjo^5
The following Case, however, deserves to be noted, inasmuch as1 QrUc?Us ^n^ammation excited in typhus most frequently involves the br ^atlgrene ^anes and cellular tissue, and has a great tendency to suppuration are oft'^ *s ^y no means invariably the case. The serous mem-plgSe.Parts a GQ ^P^cated, and the ordinary products of increased action in Sll^r|tis and^ infrequently produced, forming complications of peritonitis, e?t to ^en^nSltis. A great many examples might be given, but it will be Of ^ 6 a *"ew only to illustrate this statement." 105.
C0lUDliL!^e c?py the following, which is given as an instance of peritoni-'catmg typhus. ?k'n* Menstruation had been suppressed for three months, '?* th co,rte-^er symptoms on admission were pain in the chest and centre wit1?eSS extremities, swelling of the right leg, tongue coated &ti,j'110 Unnati f ^rown fur, bowels relaxed, evacuations dark, no pain in the WVery comp ra" sound to be detected by auscultation in the chest, pulse 128 b^vg95; On thpS^ u " "^here was in this case a mixture of the rash with pe-?pi&a Pt wen tV menstruation appeared. On the Gth she was reported to wag i 6 been no evacuation from the bowels, the pain in the by ^ ed by ,ss* She continued to improve until the 13th, when she was ressUre and d"^ fo^OWed by pain in the abdomen, the pain was increased eprived her of all rest, her pulse 130 and very feeble, her tongue [J11^ dry and brown, breathing was performed by the respiratory muscles alone, relief was obtained, and she sank on the 14th.
On examination post mortem the abdomen was found to contain a conSl^.et? ble quantity of turbid fluid mixed with flakes of lymph, and the intestine9 i coated with a layer of recent lymph which glued them slightly together. ^ There were several patches of ulceration in the ascending portion of the intestines.

jjjcb
The other viscera were sound with the exception of the fallopian tubes were observed to be filled with pus.
No perforation of any portion of the intestinal canal had taken place.
There were no morbid appearances either in the chest or head." 107-^ Now, we would ask any unbiassed man of judgment, whether, in the tJ just related, the abdominal lesions of themselves were not fully suffici? account for all the symptoms, without supposing* the existence of sped" . phus ? It will be found, on examination, that from the very commence ?^ and throughout the whole progress of the case, the leading-symptom? ^ referable to the stomach and bowels; while pain of head, delirium por, were absent, or at least are not mentioned. We are told, indee"'^, there was "no pain in the head." There were, it is true, the rash aIt] techise, but few physicians, we think, will join Dr. Roupell in attribu11^]! much importance to their presence. The gastro-intestinal derangecne ^ account satisfactorily for the former; while petechias, it is well knovv0^, present themselves in all diseases which weaken the crasis of the vita' jj;, It is with regret that we thus call in question the correctness of " ' of discrimination, or, we should rather say, classification; for on p?'n $ practice, we doubt not that he distinguishes with sufficient accuracy-^ when men write about diseases, they do not always display the sam? J / ment and caution which they employ in treating them. Either tl' ' blinded by some favorite theory, against the evidence both of reas? s, observation; or failing through negligence to consider well the s J which they discuss, they throw their remarks together loosely to . 0' waste of their readers' time and patience, and the incalculable detr'111 science. re]/j Of pneumonia occurring as a complication of typhus, our aut two cases out of many, and then proceeds to consider the state of 1 in this disease. Rasori says that it varies extremely, and Dr. R. ?lV cases confirmatory of the truth of this statement.

fiatP5!
We have thus completed a faithful and tolerably full analysis of -Ji of the work, (extending over 116 pages,) which is devoted more eSP j/' to a description of the symptoms of typhus. Of the remaining p3=^' tbe'. ever, between 50 and 60 are occupied with a re-consideration fac symptoms; and present, together with a repetition of many of previously stated, certain new observations and reflections, to some we purpose briefly to advert. , ^ Typhus, our author remarks, may terminate at the end of a j( pi^ mild yet characteristic symptoms; or, in a somewhat severer for ^ 0f $ be prolonged through the second week, with but little indicate serious organic change. uiore^ " Should, however, the disease be aggravated to a third degree* midable train of symptoms present themselves, such as blackness an . j0j),c the tongue, subsultus tendinum, tremors of the limb3, local inflai*1111 ^9] Dr. Hot/pel/ on Typhus Fever. 113 5ipelas v\eJ?rer^nnprCnG'rS^ou^'nS? l?w muttering delirium, which are too frequently 8 these la^0 ^ 'hen typhus can and often does exist without exhi-' ering them S rnen^'0lle^ exaggerations of its features, we are justified in con-it^ confin^i something superadded, or as an aggravation of a disease which Ponant j to a much more limited course.
And here we may obtain p 'ateral kno f,u j*10n as *? cause an^ treatment of these symptoms from eSence in ?4L e Se about the same phenomena, already familiar to us from their T in other diseases." 117.
p^ftiore oernfecti?n, parturition, or injury of any part of the body, there fol-s%* acconipa C-s? constitutional excitement, with a tendency to the formation of OS tend' a dry an(l I101 skin, black tongue, muttering delirium, to i?r'Se Severe"^01' s*uPor? an(l many of those formidable symptoms that cha-fg^^a-mmaticT attac^s ?f typhus. These symptoms are now properly referred Jje to be ?*" 'he inner lining of the veins, and it seems therefore a fair in-M ROICO-CHI RURfilCAL Rkvikw.
[J,,I,V attendant on phlebitis. Well, grant that they be: does it follo^ ^ " although the cause in the two cases may be different, yet the^j |( (namely, admixture of pus, &c. with the blood) in both is the sarDe\ ;]j( this were acknowledged with regard to phlebitis, we might pursue a sl jj line of argument with respect to that form of pneumonia which oCCU.ttep! unhealthy exhausted patients, low gastric fever, pestilential intend' ^ fever, &c. &c. In fact, there is no asthenic disease whatever, wbic? ^ 1 not, towards its close, present the train of symptoms generally denoi*1^ ||l typhoid. Will Dr. R. contend that in all such cases phlebitis exisfs'g to so, we should like to have his proofs, failing which, we must conti? ^ believe that the graver symptoms of typhus are no more produced by r bitis, than they are by asthenic pneumonia, low gastric fever, &c. &c; gofl After these remarks we cannot but look upon Dr. R.'s long quotati0 the subject of phlebitis as misplaced, and therefore altogether useless-us1,1,5 Hemorrhage.?The frequent occurrence of this symptom in tyP .Jfl' already been noticed. It may present itself at an early or a late per ^ the disease. In the former case, Dr. II. thinks that it depends in measure on increased activity of the vessels; in the latter, on ch^ ^ the circulating fluid itself. These two distinct forms of haemorrb3?^ I ncurring as they do under widely different circumstances, cannot. >. i> affirms, be too carefully distinguished from each other. This re. e|fi" equally applicable to the haemorrhage of purpura, which presents lS> two different forms, very distinctly marked, and of opposite Several cases of the disease in the sthenic form were, some years ag?> gS^' in St. Bartholomew's Hospital by venesection, and with the best r'ft A case related by Dr. Latham, in the first volume of the Medical ^ jl' illustrates the good effects of depletion in the form of purpura " luded to. : Erysipelas.?" The next subject which claims our attention is the of erysipelas with typhus. This occurs very frequently, so frequent') that it cannot be regarded as a fortuitous event. It appeared in one*5 .jC3, h the cases under my care in 1831, and quite as often in the later epiderejj^ was the proportion less among the cases recorded by M. Chomel. ItlS eral^ by Dr. Tweedie, that in the ' London Fever Hospital, as well as in pitals, erysipelas is by no means uncommon. Of protracted cases of Causes^ or f'Se **rom P^ts previously or recently irritated, as by cupping or other ^ider sna r?-m excoriat'ons> especially those about the nates, it extends over a may apneCC' lnv?^ving sometimes the whole trunk ; but in whatever situation it ^i^atine ?r however excited, it almost always becomes phlegmonous, terc?nsidere 1? 1 ^ormati011 of pus. The appearance of erysipelas cannot but be Valescence S ry *n some cases, as headaches will often disappear and condeath 6 ^Jocee^s rapidly afterwards, in others again it is the immediate cause c?ntagi0'Us ? d?ubt can, I think, be entertained that this form of erysipelas is aod the c '* ^ seeras> indeed, to be one of the shapes that typhus can assume, for it is n?nJec_ture may be allowed that this is the epidemic form of the disease; erysipelas 0rious that those seasons which give rise to typhus generate also ^ave been0'*"^ a Case '? s^ow that typhus can produce erysipelas, but as yet typhus frQUna^'e to sa-tisfy myself of the possibility of one person contracting to another labouring simply under erysipelas." 134. oucij n?leby ?Case? Dr. Rinforms us in a note, has been mentioned by Mr. an^e. exanthematous diseases, has already been mentioned by our ** ls ag"ain strongly urged by him as an argument in favor of the ? We p^1 "e advocates.
i Pecur?Ve-r ^r' ^"'s forther remarks on "suppuration," "gangrene," ^soiuch lar Anamination of typhus," and also " the state of the pulse," are certain morbid conditions in which before life has ceased the laws ^ ^ ' regulate all matter overcome the resistance of vitality, and while conscious0 remains and life still lingers, the system loses its power of generating "e e I chemical affinities begin to exert themselves, and putrid symptoms result, ^ J he refers to depression of nervous energy, and then goes on to notice the ( ferent modifications of external influences, which more or less are in con? ^ operation upon our frames, such as exclusion of the sun's rays, living consta"^ in a damp situation, and imperfect nutrition of the body : occupancy ^ healthy places, or deficient alimentation, at once strikes at the functions of ^ lungs and skin, the direct and indirect organs of sanguification ; wasting the circulating fluids are impoverished, the blood becomes thin, watery, dencl in fibrine, and palpably disordered." 151.
Dr. R. strenuously combats the theory which regards typhus as the re5^f of mere debility, and asks how the advocates of this theory can accoun1^, j the inflammatory results so frequently witnessed in the brain, lungs, 111 tines, &c. " A theory," he remarks, " which ascribes the origin of typhus to the tion of a specific poison producing a series of morbid actions, and proV?cticf inflammation of a modified character, must at least be less injurious in PL ^ than that doctrine which ascribes all the processes of this fever to so insu'*1 a cause as debility." 155. a a" But putrid symptoms, though they always appear in the protracted ( severer forms of typhus, are yet not absolutely essential to that disease. $ must, however, originate in some cause, and Dr. R. again attributes to vascular inflammation.
IVst?p " Should inflammation of the minuter vessels be admitted as an ca 'ep<f in typhus, an explanation will at once be afforded us of the various conseq which ensue." 158.
H els ! Is it come to this? "Should inflammation of the minuter vess admitted"?we thought our author had long ago proved its existe ^ j least to his own satisfaction. In the following passage he again e*P himself with confidence as to the truth of his theory. M j " It is one of my objects to show that typhus is an eruptive disease'of^ simple appearance of a rash proves an alteration in the natural conditio11 ^ vessels of the skin-, that*this condition is inflammatory, the sympto1?9 accompany it sufficiently attest." 15Q. ^ which is commonly called " blinking-the question." A great and aut}3 a^out inflammation of the veins, and inflammation of the arteries; rence tl ?fS are fluotei^ to shew that the former is of more frequent occur-*s cited 'f111 ^le ^atter? and that its tendency to spread is greater; and a case man wh0T ^*enc'"n' *n which pus was formed " in the arteries of a another f ^rom fever *n consequence of a wound in the hand; and "lea sles r0rn ^>orl'a^ in which the aorta of a young man who had died from ^Ver ^0Uncl to he inflamedbut with regard to the pathology of typhus examined ^VB 0n^ one so^tary observation. It is the case of a patient ti?n in 1/ ^ in whom " there were undoubted signs of inflammaramify <! ^le ^arSer arteries," the vasa vasorum being seen distinctly to Such are uP?n the aorta and its branches to a second and third degree." is the ca ar?"unients by which our author labours to prove, that phlebitis Se of all the more grave symptoms of typhus!! ?Wels. ^v, .lea(l> then of the skin, afterwards of the lungs, and, lastly, of ich regular implication of different organs would lead to the inference that irritation rather travels through the vessels, than is excited by | impression from the blood, which would act nearly simultaneously on all P8 , of the vascular parietes." 186.
Dr. R. does not, however, deny that the blood is greatly altered 1,1 [ typhus.
" It is only by the supposition that some change of an injurious tende^ takes place in the circulating fluids themselves, that we can offer an explanat' f of the symptoms by no means uncommon in certain cases during the PreV of epidemic typhus. The cases to which this allusion refers, are those in wj11 a a fatal termination takes place about the third week, when the patients ^ considerable time have been in a lethargic state, but are conscious when rou^' and declare themselves free from pain. No one organ appears to suffer lD ,e essential degree; the skin is perhaps hotter than natural, the pulse feeble* , tongue dry, hard, and black ; the breathing may possibly be somewhat hurr'.flff but auscultation can detect no disease of the lungs, nor is there any indicaleJ of essential mischief in the abdomen. Patients in this form of typhus will ot. take nourishment and occasionally exhibit signs of amendment. The fatal ter j nation of these cases is very mortifying, as it is impossible to avoid enterta"1^ expectation that they will terminate in recovery; there seems indeed no re? e I for an unsuccessful result; there are no symptoms of essential organic c to occasion it; no great excitement to exhaust the powers of life ; still a seI\jjd constitutional disorder is excited, which our remedies are unable to remove* ^ which the efforts of nature are obviously quite inadequate to oppose: 1)0 uSe examinations post-mortem, in these instances, throw any light upon the c of death, &c. &c." 192.
We have already fully expressed our opinion of Dr. R.'s views respeCf^ the part which vascular inflammation plays in the production of tyP We pass on, therefore, to his observations on the pathology of the j Glandular System.?Under this head he classes the parotid glan"' the glands of the small intestines. The submaxillary gland also, the m1& teric, the axillary, and inguinal glands are all liable to be affected. ej puration takes place sometimes in the substance of the parotid, somc in the cellular tissue around it. But the glandular follicles of the inteSt|,ey mucous membrane, are the parts chiefly affected. The lesions which ^ present, constitute, according to several eminent French pathologic?' ^ merely the origin, but the very essence of " typhoid fever." But typhoid fever of France identical with the typhus of this country ? mI author believes that it is; and yet, at the same time, he acknowledgeS' tajt " inflammation of the glands of the intestines is by no means aco^jj accompaniment of that form of typhus fever which is commonly met ^ our country." ; \ This is rather an unfortunate admission for one who argues, " that i? ^ mation of the intestinal canal, when accompanied by ulceration, is one * causes of phlebitis," and that phlebitis again is the cause of all the very ? symptoms of typhus.
The mucous membranes in typhus present, either separately or conj ,o' j various morbid alterations, the chief of which are staining,' soften1 j}.
flammation, and ulceration. Under the head of mucous membranes, tJ^ > classes all those parts to which Meckel has extended the term, incln 1 " conjunctiva, pin mater, skin, &c.

1839)
Dr. Roupell on Typhus Fever. 119 ^arvnx'S ^aS ?^serve(l that the mucous membrane of the epiglottis, glottis, P0rtionsr trac^ea *s sometimes affected, though less frequently than other ing to S ? l^e membrane lining the respiratory organs. Erysipelas, extendproved r 6 \arynx and upper portion of the trachea, has more than once rence tl^, 1]? our author's practice. Bronchitis is of such frequent occur-states\i at.^denbrand considers it essential to the disease. Dr. Tweedie at is invariably present. " The l?t 0tlj 7cous membrane of the alimentary canal is very often disordered; Part, . 8 ulceration over the patches of glands destroy the tissue in this Plated ?^ers also : thus the pharynx and oesophagus are occasionally ul-' Lo nSe which I have myself never met with, but which has been seen Ser'?uslv ?IS' ^l0 ?bserves also that the stomach is in most cases more or less Nure. ^P^icated, being either softened, attenuated, changed in colour, or 0l& 01^ declares that it was often natural, oftener indeed than in death uiner causes." 211.
there ^enito-urinary portion of this membrane it may be remarked, that Medico-chikprgical Rkvikiv.
' n lO ^ of ordinary pleurisy. Patients labouring under typhus will often remain ^ state of apathy or indifference, and unconscious of all ordinary impress'^ local disease therefore is wanting in outward demonstrations; thus p'eU( will occasion no pain, and there will be no cough, as the lungs will be sU ^ ently expanded by respiration to prevent congestion. I have known irrep^ ^ mischief produced before an idea was entertained that any disease existed chest, or that attention was drawn to the affected organ." 221. ^ But while we must be cautious not to overlook pleurisy, it is * greater moment to be on our guard against the access of pneumonia. " The comparative insensibility of the parenchyma of this organ (the will readily satisfy us of the absolute necessity of frequently resorting toa^s ^ tation, the use of which is signally exemplified in the treatment of typh"s' J()t it is not only essential to ascertain the fact whether the lungs are inflate"' ci only necessary to make out the character of the lesion, but of vital imp?r w also to know the exact spot which is diseased, for there is no strength j, thrown away, and as our measures must be depleting, they must be ately directed. In my experience the substance of the lung is affected in a all severe cases, scarcely has one patient passed through the protracted Pe^8 without oppression of the chest, hurried breathing, and small crepitation; ^ lungs, when examined after death, have presented the various stages of mation ; and not only has consolidation been discovered at the base, to ^ part it is confined by M. Louis, but I have seen it also in the upper '? j ft purulent secretion is met with occasionally throughout the structure, aIj scess will sometimes form in the upper, and indeed in every other part, case examined by me inflammation in the upper lobe of the right lung ^'e Jr rapidly to ulceration, and large cavities were formed in this portion of monary tissue." 225.
? 2> I Gangrane of the lungs is of very rare occurrence in typhus. fection would deserve more consideration, if it were not for its rarity. ' In the greater number of those who die from typhus, the substance j brain is rosy and injected. This is not remarkable, considering ^ie vascularity of the pia mater, and the intimate connexion of this toe? with the brain, by means of its numerous minute vessels. Sir John * states that he met with abscesses in the brain, and also in the cer rateand we learn from Hildenbrand that the brain will occasionally supp0 a " Dr. Bateman considers that the inflammation in this fever is ^ cept when it attacks the brain, but I do not see any reason to make an c* ^ jD?
to the general rule, because, although the brain is often greatly j though patients who have great disturbance in the functions of this ' main comatose for many days together, experience at times great utterance, and suffer from effusion, as was exemplified in the case_of yet they will recover more completely from such affections when orig"^/ typhus than is the case when similar results arise from idiopathic affection." 225.
.i , tfl'1 Here terminates our author's description of the principal lesion? o> may take place during the progress of typhus. After some commj a $ the very numerous organic changes which its poison produces, a'1 cer unimportant remarks on the classification of the disease, he then to consider the question of treatment, which he discusses at length, and with the judgment of a man well versed in the on"